How did they reach this level of concord on treatment – especially after some scientists and clinicians had advocated for delayed treatment in years past? The story starts with HAART. The game changing triple drug therapy, known as highly active antiretroviral therapy (HAART), was very literally a lifesaver when the BC Centre for Excellence in HIV/AIDS (BC-CFE) introduced it in 1996. Since then, BC-CfE research has pointed to the benefits of universal access to immediate treatment – regardless of transmission group, CD4 counts, or other variables – to any individual living with the disease.

BC-CfE research was a leader in a revolution in scientific thought that HAART should be provided universally. Dr. Julio Montaner, Director of the BC-CfE, presented the concept of Treatment as Prevention (TasP) in 2006. TasP, pioneered at the BC-CfE, means offering sustained, full access to antiretrovirals in order to dramatically reduce the spread of disease by decreasing the virus to undetectable levels. It has been implemented in many international jurisdictions and forms the basis of the UNAIDS 90-90-90 Target to end AIDS by 2030. Just this year, results released from two prominent international clinical trials confirmed the idea behind TasP: Early treatment is best when it comes to improved health outcomes. The evidence is there and it is now time for the world leaders to follow through with investment in open and universal access to HIV treatment. Investing in TasP® will pay off not only in reductions in health care costs but also in the end of AIDS within our lifetimes.

“You are either with us or you are against us,” says Dr. Montaner.

Read on to learn about top BC-CfE findings in HIV research that helped to point the way towards early, sustained and universal treatment.

1. HAART reduces mortality, particularly among those who start treatment earlyIn 1997, shortly after the introduction of highly active antiretroviral therapy (HAART) BC-CfE researchers identified the early availability of the triple drug therapy treatment reduced the mortality rate for HIV. In particular, those who started antiretroviral therapy when their CD4 counts were still relatively high experienced the greatest decline in mortality. At the time, a CD4 count measurement was required for the provision of the treatment. Today, HAART is universally provided in British Columbia regardless of CD4 count in order to ensure any person living with HIV can achieve undetectable viral load, and reduce their likelihood of transmission as early as possible.

2. Delaying HIV treatment increases mortality by up to 94%A 2009 study by BC researchers published in the New England Journal of Medicine found that, among patients with a 351-to-500 CD4 count, the deferral of antiretroviral therapy was associated with an increase in the risk of death of 69%, as compared with the early initiation. CD4 counts are indicators of the health of the immune system. Among patients with a more-than-500 CD4 count, deferred therapy was associated with an increase in the risk of death of 94%. BC-CfE researchers (as part of a study by the When to Start Consortium published in The Lancet in 2009) determined that deferred initiation of combination therapy was also associated with higher mortality rates, as well as higher rates of AIDS. The paper was based on analysis of 18 cohort studies of patients with HIV.

3. Treatment should be provided universally, regardless of transmission groupA 1998 study, conducted shortly after a steep spike in HIV diagnoses among injection drug users (IDUs), found less than half of this particular group within a sample had received therapy about one year after becoming eligible – despite the drugs being universally offered in the province. One of the possible barriers to care was that physicians considered IDUs at higher risk of developing drug resistance, as they doubted their adherence to an HIV drug regimen. Since then within British Columbia, through outreach programs designed to reach the most vulnerable populations, access to antiretrovirals has expanded to include more IDUs. The result: Today, HIV transmission rates among IDUs have dropped significantly, driving a steep decline in new HIV cases in the province.

4. Combination HIV antiretroviral therapy boosts life expectancyA 2008 study by BC researchers of 14 research cohorts in high-income countries in Europe and North America found life expectancy in HIV-infected patients treated with combination antiretroviral therapy increased between 1996 and 2005. Life expectancy at age 20 increased from 36.1 years to 49.4 years. Life expectancy was lower for those who injected drugs and those with lower CD4 counts. By 2013, research from BC had established that a 20-year-old HIV-positive adult on antiretroviral therapy in the United States or Canada could expect to live into their early 70s, a life expectancy approaching that of the general population. However, life expectancy with HIV differs according to sex, race, HIV transmission group and CD4 count. Adding to this, a 2015 study led by the BC-CfE, based on data from the largest Canadian research cohort of individuals living with HIV on ART, found life expectancy for those with HIV remains below that of the general Canadian population. Delayed treatment is one of the factors leading to lower life expectancy.

5. Adherence is essential to survival. BC-CfE research demonstrates, even after adjusting for other prognostic factors, intermittent use of antiretroviral therapy is associated with increased mortalityIntermittent therapy was defined as the participant having obtained less than 75% of their medication in the first 12 months. A 2000 study found adherence levels of 95% or higher was associated with high virologic success, which drops sharply with decreasing levels of adherence.

AND ANOTHER IMPORTANT FINDING...6. Poverty and other socioeconomic factors can pose barriers to accessing HIV treatmentBC-CfE research has investigated the socioeconomic factors affecting HIV treatment and mortality rates. A 1994 study found low-income status was associated with higher risk of death amid a cohort of over 300 men living with HIV. A 2008 study found environments could also affect health outcomes. In a setting where treatment for HIV universally offered, a significant number of HIV-positive persons did not access treatment – particularly those living in neighbourhoods with lower economic status. The report recommended social and health policy initiatives, beyond universal health care, to optimize access to HAART. Conversely, access to treatment can open pathways to other sources of wellbeing. BC-CfE research announced in 2015 shows people starting HIV treatment for the first time are more likely to transition out of homelessness, start addiction treatment, and begin a romantic relationship.

Don’t forget to join the BC-CfE on October 27. Dr. Montaner and other experts from the BC-CfE will explore the history TasP, and the results of its implementation in Canada and internationally. The event is part of the University of British Columbia’s Centennial Celebration and all are welcome!